Advanced practice nursing core concepts for professional role development

Advanced Practice Nursing Advanced Practice Nursing Core Concepts for Professional Role Development Core Concepts for Professional Role Development Fifth Edition Fifth Edition Fi fth Edition Kathryn A. Blair Michaelene P. Jansen Editors Jansen Blair Kathryn A. Blair, PhD, FNP-BC, FAANP Michaelene P. Jansen, PhD, RN-C, FNP-C, GNP-BC, FAANP Editors Designated a Doody’s Core Title! Earned a 5-star 100 Score, Doody’s Medical Review The fifth edition of this topflight text on nurse practitioner role development is completely updated and expanded to encompass the full sphere of current practice roles. These include interprofessional, global health, and leadership roles and such practice issues as credentialing, prescriptive authority, and liabilities. The book encompasses the diverse expertise of contributors from a wide variety of practice settings and reflects the competencies identified by key stakeholder organizations such as the ANA, NONPF, NACNS, AANA, ACNM, and AACN. With a focus on everyday realities of APRN practice in a rapidly changing health care environment, it delivers essential information on the multifaceted role of APRNs as they transition into practice and professional arenas. The fifth edition reflects the expanding roles of the DNP and CNL and provides more detail on the transition of APRN master’s and doctoral students—particularly NPs, CNSs, CNMs, and CRNAs— into practice. It discusses the impact of the Patient Protection and Affordable Care Act on health care delivery and emphasizes the APRN role in influencing health policy. New chapters address global health and differentiated roles for the APRN and APRN leadership in interprofessional teams. The text provides new information on practice issues such as credentialing, prescriptive authority, and liabilities, along with updated web resources. Additionally, the fifth edition includes an enhanced discussion of educational requirements and differentiation from certification and expanded coverage of professional issues and research-based practice (including quantitative and qualitative methodologies). The book continues to provide essential information on advanced clinical decision making, reimbursement, ethical issues, technology, and employment strategies for the APRN. New to the Fifth Edition: • A chapter on global health and differentiated roles for APRNs • A chapter on APRN leadership in interprofessional teams • Current information on practice issues including credentialing, prescriptive authority, and liabilities • Updated web resources • Enhanced discussion of educational requirements and differentiation from certification • Added content about DNP and CNL roles and leadership functions • Expanded coverage of professional issues and evidence-based practice • Information on influencing health policy • Content on integrating informatics in practice • Online teaching tools that include PowerPoint slides and an instructor’s manual 11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com 9 780826 172518 ISBN 978-0-8261-7251-8 Advanced Practice Nursing

Advanced Practice Nursing Blair_72518_PTR_00_i-xii_FM_03-20-15.indd i 20/03/15 12:52 PM

Kathryn A. Blair, PhD, FNP-BC, FAANP, is nurse practitioner option coordinator and professor at Beth El College of Nursing and Health Sciences, University of Colorado at Colorado Springs. Her academic experience spans more than three decades. Dr. Blair has more than 25 years of experience in family medicine and most recently began practicing in allergy and immunology. Dr. Blair remains active in various state and national professional organizations. Michaelene P. Jansen, PhD, RN-C, FNP-C, GNP-BC, FAANP, is a family and gerontological nurse practitioner at Essentia Health Ashland Clinic in Ashland, Wisconsin. She is also professor emeritus of nursing, College of Nursing and Health Sciences, University of Wisconsin–Eau Claire. Her professional nursing experiences include critical care and trauma. She has coedited four editions of Advanced Practice Nursing, Core Concepts for Professional Role Development and edited Pain Management of the Older Adult (Springer Publishing). Blair_72518_PTR_00_i-xii_FM_03-20-15.indd ii 20/03/15 12:53 PM

Advanced Practice Nursing Core Concepts for Professional Role Development Fifth Edition Kathryn A. Blair, PhD, FNP-BC, FAANP Michaelene P. Jansen, PhD, RN-C, FNP-C, GNP-BC, FAANP Editors Blair_72518_PTR_00_i-xii_FM_03-20-15.indd iii 20/03/15 12:53 PM

Copyright © 2015 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Production Editor: Kris Parrish Composition: GW Tech. Pvt. Ltd. ISBN: 978-0-8261-7251-8 e-book ISBN: 978-0-8261-7252-5 Instructor’s Manual ISBN: 978-0-8261-9434-3 PowerPoint Slides ISBN: 978-0-8261-9433-6 Instructor’s Materials: Instructors may request supplements by emailing [email protected] 15 16 17 18/ 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Advanced practice nursing (Jansen) Advanced practice nursing : core concepts for professional role development / Kathryn A. Blair, Michaelene P. Jansen, editors.—Fifth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-7251-8—ISBN 978-0-8261-7252-5 (e-book) I. Blair, Kathryn A., editor. II. Jansen, Michaelene P., editor. III. Title. [DNLM: 1. Advanced Practice Nursing. 2. Nurse’s Role. WY 128] RT82.8 610.7306’92--dc23 2014048132 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370; Fax: 212-941-7842 E-mail: [email protected] Printed in the United States of America by Bang Printing. Blair_72518_PTR_00_i-xii_FM_03-20-15.indd iv 20/03/15 12:53 PM

CONTENTS Contributors vii Preface xi PART I: FOUNDATIONS OF ADVANCED NURSING PRACTICE 1 Overview of Advanced Practice Registered Nursing 3 Linda L. Lindeke, Melissa Avery, and Kathryn W. White 2 Advanced Practice Within a Nursing Paradigm 27 Gail B. Katz 3 Multifaceted Roles of the APRN 41 Jana Gail Zwilling 4 Advanced Practice Nursing Within Health Care Settings: Organizational Roles 57 Jana Gail Zwilling 5 Interprofessional Collaborative Teams and Education: Roles for the APRN 67 Kathryn A. Blair 6 Global Health: Dynamic Roles for the APRN/APN 77 Kathy J. Wheeler, Lorna L. Schumann, Gene Harkless, Catherine G. Ling, Beverly Bird, and Patricia Maybee 7 Leadership Skills and Expertise: Keys to APRN Success in Health Care Systems 123 Janet Wessel Krejci and Shelly Malin PART II: IMPLEMENTATION OF THE APRN ROLE 8 Advanced Clinical Decision Making 145 Rhonda D. Squires 9 Health Care Policy: Implications for Advanced Nursing Practice 167 Evelyn G. Duffy v Blair_72518_PTR_00_i-xii_FM_03-20-15.indd v 20/03/15 12:53 PM Share Advanced Practice Nursing: Core Concepts for Professional Role Development, Fifth Edition

vi Contents 10 Practice Issues: Regulation, Certification, Clinical Privileges, Prescriptive Authority, and Liability 185 Michaelene P. Jansen 11 Reimbursement Realities for the APRN 209 Cheri Friedrich and Linda L. Lindeke 12 Ethical Issues in Advanced Practice Nursing 231 Karen S. Feldt 13 Evidence-Based Practice: Staying Informed and Translating Research Into Practice and Policy 243 Kathryn A. Blair 14 Health Information Technology for the APRN 257 Vicki J. Brownrigg PART III: TRANSITIONS TO THE ADVANCED PRACTICE ROLE 15 Scholarship of Practice and Professionalism 281 Kathryn A. Blair and Patricia A. White 16 Employment Strategies for the APRN 291 Shirley E. Van Zandt 17 Inaugurating Your Advanced Practice Career 311 Carole G. Traylor Index 317 Blair_72518_PTR_00_i-xii_FM_03-20-15.indd vi 20/03/15 12:53 PM

Melissa Avery, PhD, RN, CNM, FACNM, FAAN Professor and Chair School of Nursing University of Minnesota Minneapolis, Minnesota Beverley Bird, MPH, MSN, B.AppSci, RN, MCHN, FACN Lecturer (Adjunct) Faculty of Medicine, Nursing, and Health Sciences Monash University, Clayton Campus Clayton, Victoria, Australia Kathryn A. Blair, PhD, FNP-BC, FAANP Professor, Family Nurse Practitioner Program Coordinator Beth El College of Nursing and Health Sciences University of Colorado–Colorado Springs Colorado Springs, Colorado Vicki J. Brownrigg, PhD, FNP Assistant Professor Beth El College of Nursing and Health Sciences University of Colorado–Colorado Springs Colorado Springs, Colorado Evelyn G. Duffy, DNP, AGPCNP-BC, FAANP Associate Professor in the School of Nursing Associate Director of the University Center on Aging and Health Francis Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio Karen S. Feldt, PhD, GNP-BC Clinical Educator Matrix Medical Network Pownal, Vermont CONTRIBUTORS vii Blair_72518_PTR_00_i-xii_FM_03-20-15.indd vii 20/03/15 12:53 PM

viii Contributors Cheri Friedrich, DNP, RN, CNP Clinical Assistant Professor School of Nursing University of Minnesota Minneapolis, Minnesota Gene Harkless, DNSc, APRN, FAANP, CNL Associate Professor of Nursing, Chair of Department of Nursing College of Health and Human Services University of New Hampshire Durham, New Hampshire Michaelene P. Jansen, PhD, RN-C, FNP-C, GNP-BC, FAANP Family and Gerontological Nurse Practitioner Essentia Health Ashland Clinic Professor Emeritus University of Wisconsin Eau Claire, Wisconsin Gail B. Katz, DNP, RN, CNS Assistant Professor Beth El College of Nursing and Health Sciences University of Colorado Colorado Springs, Colorado Janet Wessel Krejci, PhD, RN, NEA-BC Interim Vice President for Academic Affairs and Provost Illinois State University Normal, Illinois Linda L. Lindeke, PhD, RN, CNP, FAAN Associate Professor School of Nursing University of Minnesota Minneapolis, Minnesota Catherine G. Ling, PhD, FNP-BC, FAANP Daniel K. Inouye Graduate School of Nursing Uniformed Services University Bethesda, Maryland Shelly Malin, PhD, RN Advocate BroMenn Endowed Professor Illinois State University, Mennonite College of Nursing Normal, Illinois viii Blair_72518_PTR_00_i-xii_FM_03-20-15.indd viii 20/03/15 12:53 PM

Contributors ix Patricia Maybee, EdD, FNP-BC, NP-C, FAANP Family Nurse Practitioner Primary Care Department Gila River Health Care Sacaton, Arizona Lorna L. Schumann, PhD, NP-C, ACNP-BC, ACHS-BC, CCRN-R, FAANP American Academy of Nurse Practitioner Certification Program Austin, Texas Rhonda D. Squires, PhD, APRN-BC, FNP Assistant Professor, Master's/DNP FNP Programs Coordinator School of Nursing University of Northern Colorado Greeley, Colorado Carole G. Traylor, DNP, RN, CPNP, AE-C Assistant Professor Beth El College of Nursing and Health Sciences University of Colorado Colorado Springs, Colorado Shirley E. Van Zandt, MS, MPH, CRNP Clinical Assistant Professor School of Nursing Boise State University Boise, Idaho Kathy J. Wheeler, PhD, APRN-FNP, NP-C, FAANP Assistant Professor School of Nursing University of Kentucky Lexington, Kentucky Kathryn W. White, DNP, RN, CRNA Clinical Associate Professor, Program Director and Coordinator Nurse Anesthesia Specialty School of Nursing University of Minnesota Minneapolis, Minnesota Patricia A. White, PhD, ANP-BC Professor of Practice Director of the DNP Program Simmons School of Nursing and Health Sciences Boston, Massachusetts Blair_72518_PTR_00_i-xii_FM_03-20-15.indd ix 20/03/15 12:53 PM

Jana Gail Zwilling, MSN, FNP-C Clinical Instructor College of Nursing and Professional Disciplines University of North Dakota Grand Forks, North Dakota x Contributors Blair_72518_PTR_00_i-xii_FM_03-20-15.indd x 20/03/15 12:53 PM

The fifth edition of Advanced Practice Nursing: Core Concepts for Professional Role Development carries on the tradition of the previous four editions: updating current trends in practice; reviewing the origins, standards, and competencies of the advanced practice registered nurses (APRNs) in the United States; discussing APRN roles within a nursing context; identifying organizational roles for APRNs; and examining ethics in guiding APRN clinical decision making. Previous editions have focused primarily on nurse practitioners, whereas this edition examines and addresses all four APRN roles. As with similar texts, this edition offers a synopsis of translating research into practice with emphasis on implementing evidence-based practice and how to stay up to date with current research. Useful tools in advanced clinical decision making, practice issues (regulation, certification prescriptive authority, credentialing, and liability), and the exploration of employment opportunities and strategies are reviewed. Content assisting the novice APRN in developing entrepreneur models of care and in transitioning from a professional nursing role to an advanced practice role is included. As advanced practice nursing continues to evolve and expand, new material addressing the upcoming challenges for APRNs has been incorporated into this edition. For decades the mantra in health care has been the need for collaborative interprofessional teams (IPTs). Chapter 5 explores the role of the APRN in the team’s formation and leadership. This chapter discusses the composition of IPTs that will include a variety of health care providers, but in some cases, community leaders, corporate chief executive officers (CEOs), technology experts, and others as well. The author challenges APRNs to assume more prominent leadership roles in health care delivery systems. With the movement toward expanding the APRN role in collaborative IPT, new skills and understanding of leadership competencies are needed. These concepts are explored in Chapter 7. This revised chapter emphasizes the importance of leadership competencies necessary for the delivery of quality care, evidence-based practice, and patient safety. Different leadership development models and curricula related to leadership in master’s and doctorate of nursing practice (DNP) programs are considered. Health issues have become global, as evidenced by recent infectious disease outbreaks and by the prominence of organizations such as the World Health Organization, Doctors Without Borders, Sigma Theta Tau International Nursing Society, and International Council of Nursing. The demand for APRNs is extending beyond the borders of the United States. A PREFACE xi Blair_72518_PTR_00_i-xii_FM_03-20-15.indd xi 20/03/15 12:53 PM

new chapter, Chapter 6, describes the multifaceted roles of APRNs internationally. As the advanced practice role emerges and evolves internationally, new opportunities for APRNs have surfaced. Roles such as (a) developing programs of study for U.S. students, (b) instituting cross-cultural exchange programs, (c) providing direct patient care in the form of mission trips, (d) assisting in the design and evaluation of educational programs for the advanced nursing practice role in developing countries, (e) identifying research partnerships and conducting research, and (f) influencing policies that improve health are presented. The recent change in health care, the Patient Protection and Affordable Care Act (ACA), has placed APRNs on the front lines of health care reform. This legislation has resulted in an increased demand for APRNs to meet the health care needs of those previously uninsured or underinsured. Several reports by the Institute of Medicine (IOM) have argued that the time is right for all nurses to function to their full capacity and that the barriers for advanced practice nursing need to be removed. Chapter 9 argues this is the “golden age” for APRNs. This chapter reviews the critical events that have sculpted the APRN policy role in influencing and creating legislation and discusses how to become an engaged citizen in directing change. Chapter 14 has been revised and expanded and discusses health information technology (HIT) competencies for nurses and APRNs, as well as common information management resources that APRNs are using or likely to encounter in the near future. The chapter explores meaningful use as described in Health Information Technology for Economic and Clinical Health legislation and includes a discussion of select HIT controversies and failures. All APRNs are scholars. APRNs should therefore be actively engaged in the scholarship of practice. Chapter 15 explores the multiple modalities that are incorporated into the scholarship of practice such as sharing tricks of the trade, completing quality improvement projects, collaborating with nursing researchers, and being an active member in professional organizations. The chapter highlights the tools to disseminate knowledge, which is critical for the scholarship of practice. Woven throughout the text is the evolution of nursing education for APRNs in the context of the DNP. The future of APRN education will be the DNP as the norm rather than as the exception. The DNP-educated APRN will be able to bring to the table a broader knowledge base of populationbased health care, organizational systems, leadership skills, utilization of best practices or evidence-based practice, and meaningful use of electronic information systems. Material to accompany this book’s content for qualified instructors is available from Springer Publishing Company by e-mailing textbook @springerpub.com. As with previous editions, this text equips the APRN student. This edition continues to share the tools for success in the multidimensional advanced practice role. Kathryn A. Blair Michaelene P. Jansen xii Preface Blair_72518_PTR_00_i-xii_FM_03-20-15.indd xii 20/03/15 12:53 PM

Blair_72518_PTR_01_001-026_03-20-15.indd 2 20/03/15 12:53 PM Share Advanced Practice Nursing: Core Concepts for Professional Role Development, Fifth Edition

PART I: FOUNDATIONS OF ADVANCED NURSING PRACTICE Blair_72518_PTR_01_001-026_03-20-15.indd 1 20/03/15 12:53 PM

Blair_72518_PTR_01_001-026_03-20-15.indd 2 20/03/15 12:53 PM

Advanced practice registered nurses (APRNs) are at the forefront of the rapidly changing health care system, filling myriad roles in organizations where they provide cost-effective, high-quality care. APRNs are found in virtually every area of the American health care system: clinics, hospitals, community health, government, administration, policy making boards, and private practice. In addition, APRNs have expanded practice into international and trans-global arenas. They serve the most economically disadvantaged as well as the elite. APRNs are deans, educators, consultants, researchers, policy experts, and, of course, outstanding clinicians. Advanced practice registered nursing is an exciting career choice with many opportunities and challenges. The challenges are sometimes related to health care reform that is polarized and responsive to rapidly evolving political influences. Prospective payment systems, decreased hospital stays, health inequities, and spiraling costs are daily APRN practice realities. Technology produces amazing diagnostic and treatment results; genetic research is unraveling complex pathophysiology; and sophisticated “big data” electronic infrastructures change the way information is gathered, stored, analyzed, and shared. Innovative care models are common and include home health care programs, integrated or complementary modalities, and retail clinics. These and other trends result in a rapidly changing health care system, ready for the influence and influx of APRNs. Graduate education prepares APRNs to be key players in these complex systems. Midrange nursing theories provide strong conceptual foundations for APRN practice and nurse scholars. Nursing research uncovers scientific evidence for best practice, and research utilization skills enable APRNs to bring fresh ideas and proven interventions to health care consumers. 3 1 Linda L. Lindeke, Melissa Avery, and Kathryn W. White OVERVIEW OF ADVANCED PRACTICE REGISTERED NURSING Blair_72518_PTR_01_001-026_03-20-15.indd 3 20/03/15 12:53 PM

4 I Foundations of Advanced Nursing Practice Complex reimbursement policies and mechanisms require that APRNs navigate reimbursement, management, and health policy regulations. Although APRNs were traditionally educated to provide advanced nursing care in specific clinics or hospital units, they now often work across system boundaries as they follow their patients through transitions of care. For example, APRNs care for patients in outpatient clinics, admit them to the hospital, assist in coordinating discharge plans, and collaborate with long-term care organizations, perhaps working with public health agencies to return their patients to their home communities. These new crosssystem care models result in regulatory complexity for APRNs. They must be able to legally provide care across systems. Working across state lines results in even more issues because each state has its own laws and rules. In addition, each health care organization can interpret state and federal laws and regulations in its own professional staff policies. Organizations can be more restrictive than laws, but they cannot be less restrictive. Given considerable variations among practice environments, APRNs must be experts and proactive in the business and regulatory policies and processes. Staying current is best accomplished by participation in role-specific APRN professional organizations. ADVANCED PRACTICE REGISTERED NURSING: THEN AND NOW Advanced specialization of nurses beyond their formal entry-level education has a long and proud history of many innovative risk takers and key events. To capture that history and unify the advanced nursing specialists, the term advanced practice registered nurse (APRN) became the common umbrella term used to designate four specialty roles of nurses with formal postbaccalaureate preparation: certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs). Nurse anesthetists and nurse-midwives organized nearly a century ago and were the first APRNs to develop national standards for educational programs, professional organizations, and certification. NPs and CNSs standardized their preparation, certification, and licensing incrementally in recent decades. Various scholars and professional organizations have documented the unique history of each APRN role. A number of factors led nursing leaders to delineate these four APRN roles. A critical factor was obtaining legal status to be directly reimbursed for their nursing services, a gradual process first achieved by nursemidwives more than 30 years ago and subsequently expanded through federal and state legislation for the other three roles. Reimbursement laws and regulations require that nursing be able to specify the qualifications of these reimbursable APRNs, which contributed to increased standardization of titling, education, and national certification. Public protection was another factor that led to the delineation of the APRN roles. State boards of nursing are mandated by state legislatures to Blair_72518_PTR_01_001-026_03-20-15.indd 4 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 5 safeguard the public from unsafe practice, and over time, all states have implemented laws and regulations to ensure that nurses in the four roles have specific expertise and skills. Some states have accomplished this through a second-level licensure process. In other states, APRNs are regulated through title protection and scope of practice laws. In 2008, APRNs reached an agreement defining a desired national model of regulation for the United States. This agreement, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education, is known as the LACE model (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). By mid-2014, the LACE model had been enacted in 19 states through complex legislative initiatives (Kopanos, 2014). Most other states’ APRN groups are working toward amending state nurse practice laws by adopting the LACE model of regulation. A final factor influencing APRN standardization has been the adoption of national APRN curricular guidelines and program standards. These standards were developed by many specialty organizations and brought through negotiations to consensus by nursing organizations such as the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), and the National Organization of Nurse Practitioner Faculties (NONPF). APRN educational standards have been endorsed by numerous nursing specialty organizations in the past decade and are used for national program accreditation. Nursing’s Scope and Standards of Practice (ANA, 2010) defines APRNs as having advanced specialized clinical knowledge and skills through master’s or doctoral education that prepares them for specialization, expansion, and advancement of practice. Specialization is concentrating or limiting one’s focus to part of the whole field of nursing. Expansion refers to the acquisition of new practice knowledge and skills, including knowledge and skills legitimizing role autonomy within areas of practice that overlap traditional boundaries of medical practice. Advancement involves both specialization and expansion and is characterized by the integration of theoretical, research-based, and practical knowledge that occurs as part of graduate education in nursing. This APRN definition, which is regulated by state and federal laws, does not include nurses with advanced preparation for administration, education, public health or research; those roles are considered “advanced nursing practice” and are not regulated, a fine but important legal distinction. APRNs are educated within master’s or doctoral nursing programs. Although CNSs have always required master’s nursing degrees, in the past nurse-midwives, nurse anesthetists, and NPs were not all prepared in graduate nursing programs. Now, however, NPs must receive their education in graduate master’s or clinical doctoral programs in nursing. CRNAs are prepared in graduate programs, although the master’s degree does not necessarily have to be in nursing. Although the majority of CNMs are prepared in graduate nursing programs, some nurse-midwifery programs are located in health-related professional schools. Blair_72518_PTR_01_001-026_03-20-15.indd 5 20/03/15 12:53 PM

6 I Foundations of Advanced Nursing Practice Because of their unique historical underpinnings, members of each APRN category have strong allegiance to their titles and their professional organizations. At times, this allegiance has been a barrier to the development of consistent language regarding APRN roles because each group has developed its own education, history, and titles. However, significant progress continues to be made in identifying commonalities. Research-based practice (sometimes called evidence-based practice) is a key characteristic of APRN practice. Clinical doctoral nursing programs emphasize and expand the utilization of evidence-based practice, especially in terms of preparing APRNs to be organizational change agents. Through a consensus-building process, the AACN formulated curricular elements for graduate APRN education (AACN, 2011), specifying the content of the graduate core curriculum and the advanced practice nursing core curriculum in master’s programs (Exhibit 1.1). Practice doctoral nursing programs are based on the Essentials of Doctoral Nursing Education for Advanced Practice Nurses (AACN, 2006; Exhibit 1.2). The role-specific professional nursing organizations have further delineated specialized core competencies; documents are readily available on their websites and are frequently updated. The core clinical content requires advanced health and physical assessment, advanced physiology and pathology, and advanced pharmacology (often referred to as the three Ps). These courses must be taught across the life span, with additional specific content required for students in each specialty area. For example, nurse-midwifery students need additional content on assessment of pregnant women and newborn infants, nurse anesthetist students require extensive content on anesthetic agents, and psychiatric/mental health students need additional content on antipsychotic medications. Exhibit 1.1 ESSENTIAL ELEMENTS OF MASTER’S CURRICULUM FOR ADVANCED PRACTICE NURSING I. Background for Practice From Sciences and Humanities II. Organizational and Systems Leadership III. Quality Improvement and Safety IV. Translating and Integrating Scholarship Into Practice V. Informatics and Healthcare Technologies VI. Health Policy and Advocacy VII. Interprofessional Collaboration for Improving Patient and Population Health Outcomes VIII. Clinical Prevention and Population Health for Improving Health IX. Master’s-Level Nursing Practice Source: American Association of Colleges of Nursing (2011). Blair_72518_PTR_01_001-026_03-20-15.indd 6 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 7 There are also professional ethics standards for APRNs. In addition to issues related to confidentiality and relationships, APRNs must provide support to patients and families in making ethical decisions related to treatment options (ANA, 2013). Although ethical issues appear to be more prominent in tertiary care settings, issues such as abuse and neglect are present in all settings. APRNs are frequently called on to work with professional colleagues, patients, and families to resolve ethical dilemmas. All APRNs collaborate with other health professionals. Collaboration is a standard of ARPN care and is also referenced in state and federal law. Functioning on interdisciplinary teams or working in teams with other health professionals, APRNs need to clearly identify their unique contributions to patient outcomes. APRNs also collaborate with patients and their families in planning care and making decisions about the most acceptable treatments. One emerging area of scholarship emphasizes APRN care outcomes (Kapu & Kleinpell, 2012), especially essential in this era of health care reform. A new term is comparative effectiveness research (CER), promoted by the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM). Given their history of cost-effectiveness, good patient satisfaction, and high-quality outcomes, APRNs should fare well in CER studies focused on APRN care models and outcomes. A critical review of relevant APRN outcomes research (Newhouse et al., 2011) is a milestone document that summarizes nursing effectiveness and APRN-sensitive indicators of care quality. Exhibit 1.2 ESSENTIALS OF DOCTORAL EDUCATION AND COMPETENCIES FOR ADVANCED NURSING PRACTICE I. Scientific Underpinnings for Practice II. Organizational and Systems Leadership for Quality Improvement and Systems Thinking III. Clinical Scholarship and Analytical Methods for Evidence-Based Practice IV. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care V. Health Care Policy for Advocacy in Health Care VI. Interprofessional Collaboration for Improving Patient and Population Health Outcomes VII. Clinical Prevention and Population Health for Improving the Nation’s Health VIII. Advanced Practice Nursing Source: American Association of Colleges of Nursing (2006). Blair_72518_PTR_01_001-026_03-20-15.indd 7 20/03/15 12:53 PM

8 I Foundations of Advanced Nursing Practice APRNs and Doctoral Education The previous description of content in APRN education and professional standards demonstrates the complexity and depth of APRN preparation and practice. Some nurse leaders question whether APRNs can be fully prepared for their scope of practice in 2-year master’s programs. This has prompted discussion of the feasibility of doctoral preparation being required for APRN practice (Edwardson, 2004). Doctoral APRN education existed in nursing doctorate (ND) programs as early as the mid-1980s at Rush University, Case Western Reserve University, and the University of Colorado, all of which awarded ND degrees to students completing NP programs. These ND programs have now discontinued the ND degrees; they have been replaced by doctorate of nursing practice (DNP) degrees. The DNP is a new degree first advocated by the AACN and the NONPF. In October 2004, the nation’s nursing deans attending AACN passed a resolution to move APRN education to a practice doctorate level by 2015. Although a recommendation rather than a mandate, much progress has been made in increasing the number of NPs with doctoral degrees in the past decade. More than 240 DNP programs were under way nationwide by early 2014 (AACN, 2014). There are pros and cons related to the DNP degree. The increased time and cost for students is balanced by the increase in knowledge, skill, and prestige that this doctoral degree confers. Pharmacy, audiology, physical therapy, and psychology have doctoral education as their entry to practice. The practice community has quite quickly embraced the DNP preparation; however, whether employers will compensate DNP graduates at levels commensurate with their education is undecided. Physician reactions to the nursing practice doctorate has been mixed; for example, several states have implemented legislation that reserves the term doctor for physicians in clinical arenas. A joint dialogue statement eloquently points out that “Graduate educational programs in colleges and universities in the United States confer academic degrees, which permit graduates to be called ‘doctor.’ No one discipline owns the title ‘doctor’” (Nurse Practitioner Roundtable, 2008). The DNP degree continues to be debated; regardless, the new degree is propelling APRN roles forward with new knowledge and abilities at a time when health care reform is at the forefront of the national conversation. Understanding each of the roles is essential. Nurse Practitioners NPs are registered nurses with master’s or doctoral nursing preparation who perform comprehensive assessments, promote health, and treat and prevent illness and injury. In doing so they diagnose, develop differential diagnoses, and order and interpret diagnostic tests. They prescribe pharmacologic and nonpharmacologic treatments while providing care in primary, acute, and long-term care settings. NPs specialize in certain populations of patients and in areas such as family, adult/geriatric, pediatric, Blair_72518_PTR_01_001-026_03-20-15.indd 8 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 9 and psychiatric/mental health. NPs practice autonomously and in collaboration with other health care professionals as researchers, consultants, and patient advocates. The role first developed in primary care settings. However, NPs now function in tertiary care, and specific competencies and examinations have been developed for acute-care NPs (NONPF, 2004). Health promotion and health maintenance are emphasized in all the ARPN nursing standards. Nurses have traditionally emphasized health promotion activities as being a key characteristic of the professional practice of nursing. Health promotion, whether it is for persons who have no specific illness or for persons who have chronic health problems, is critical in our current society. Implementation of care that focuses on health promotion also has been shown to be cost effective (Mundinger et al., 2000; Safriet, 1998). Horrocks, Anderson, and Salisbury (2002) noted that NPs offered more advice on self-care and management than did physicians, and they seemed to identify physical abnormalities more frequently. However, there was no difference in patient health outcomes between the NP- and physicianmanaged patient groups. The NP movement began at the University of Colorado; Loretta Ford, PhD, RN, and Henry Silver, MD, both full professors, collaborated to launch a postbaccalaureate program to prepare nurses for expanded roles in the care of children and their families. Professors Ford and Silver (Ford, 1979) recognized that nurses had the ability to assess children’s health status and define appropriate nursing actions. The purpose of the first NP demonstration project was to implement new roles to improve the safety, efficacy, and quality of health care for children and families (Ford, 1979). Although the project’s initial focus was on children and families, Ford noted that she was confident that nurses could be educated to meet the health needs of community-dwelling persons across the life span. Nurses in the Colorado program received 4 months of intensive didactic education in which assessment skills and growth and development were emphasized. The nurses then completed a 20-month precepted clinical rotation in a community-based setting. Following Colorado’s lead, many schools initiated educational programs, admitting nurses with varying levels of educational preparation. The growth of the NP movement was facilitated by many studies through the years, such as those summarized in a meta-analysis by Brown and Grimes (1995). Over the years, NPs have demonstrated that they safely provide high-quality health care, and the NP role has expanded into many new practice areas (Martin, 2000; Mundinger et al., 2000; Newhouse et al., 2011). Although Dr. Ford’s goal initially was to prepare NPs within master’s programs, societal demand for NPs led to a proliferation of postbaccalaureate continuing education programs rather than graduate education (Ford, 1979, 2005). Federal funding for NP programs also prompted the initiation of numerous postbaccalaureate and graduate NP programs. The length of these early NP programs varied from a few weeks to 2 years, with many certificate programs being 9 to 12 months in length. Blair_72518_PTR_01_001-026_03-20-15.indd 9 20/03/15 12:53 PM

10 I Foundations of Advanced Nursing Practice The proliferation of postbaccalaureate programs rather than graduate programs for the education of NPs was partially attributable to the resistance of graduate nursing programs to recognize NPs as being a legitimate part of nursing. A number of nursing leaders termed NPs “physician extenders” and did not view NP practice as “nursing.” This lack of enthusiasm for NP education exhibited by numerous nursing leaders in the 1960s and 1970s may also have been fostered by the fact that the NP movement grew out of a collaborative nurse–physician effort rather than being solely initiated by nurses. The early NP curricula were viewed as being based on the medical model rather than a nursing framework, although that was not the focus of Dr. Ford’s original NP curriculum, which emphasized child development and health promotion (Ford, 1979). The NP domains and competencies were based on the work by Brykczynski (1989), Benner (1984), and Fenton (1985). The seven domains are (a) management of client health/illness status, (b) NP–patient relationship, (c) teaching/coaching function, (d) professional role, (e) management and negotiation of health care delivery systems, (f) monitor and ensure the quality of health care practice, and (g) culturally sensitive care (NONPF, 2006). Specific competencies are described for each domain. These domains are detailed and encompassing, indicating that APRN practice requires a broad range of knowledge and expertise. Recently, NONPF (2012) revised the domains for all NP programs and developed nine core competencies: scientific foundation, leadership, quality, practice inquiry, technology and information literacy, policy, health delivery system, ethics, and independent practice. NPs are prepared in a multitude of specialties, including acute care, adult health, family health, gerontology, pediatrics, psychiatry, neonatology, and women’s health. Population-specific competencies have been elaborated and defined (NONPF, 2013). The ANA, along with other organizations, has developed many types of practice standards, some broadly inclusive and others specialty focused (ANA, National Association of Pediatric Nurse Practitioners [NAPNAP], & Society of Pediatric Nurses [SPN], 2010). For example, the ANA, NAPNAP, and SPN created a joint document that outlines pediatric nursing competencies at both basic and advanced practice levels. The American Academy of Nurse Practitioners (AANP, 2013) estimated that there were more than 190,000 NPs in the United States in 2013, 95% of whom were prepared with graduate degrees and 97% with national certification in their NP specialties. Many NPs assume positions that combine clinical practice with employment as educators, administrators, and policy makers or choose other employment. After completing graduate education, NPs are eligible to sit for national certification examinations in their specialty areas. Certification is a mechanism for the nursing profession to attest to the entry-to-practice knowledge of NPs. The certification requirement has been adopted by third-party payers such as the Centers for Medicare & Medicaid Services (CMS) and by most state boards of nursing as a standard that assists in protecting the public from unsafe providers. Certification examinations are offered by a variety Blair_72518_PTR_01_001-026_03-20-15.indd 10 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 11 of bodies: the American Nurses Credentialing Center (ANCC), the AANP, the Pediatric Nursing Certification Board (PNCB), the American Association of Critical Care Nurses (AACCN), and the National Certification Corporation (NCC) for the obstetric, gynecologic, and neonatal specialties. Changes in reimbursement laws, regulations, and policies that allow for direct reimbursement of NPs, the rapid increase in managed care as a mechanism to control health care costs, and the growing recognition of the significant contributions of NPs to positive patient outcomes have resulted in a rapid increase in the number of NP programs, particularly DNP programs. The American Association of Nurse Practitioners (AANP, 2013) estimated that 14,000 new NPs graduated in 2011–2012. APRNs who are savvy about ascertaining the gaps in health care and designing roles for themselves that are not merely physician-replacement roles are likely to be very successful in obtaining satisfactory employment. Scope of practice is regulated by state laws and describes the legal boundaries of health professional practice. NPs practicing outside the designated scope of practice risk legal sanctions and potential liability (Klein, 2005). Changes in scope of practice reflect the dynamic evolution of NP roles. However, great variability exists regarding the regulation of acute and primary care NPs by individual states. Relative to CNMs and CRNAs, NPs have a relatively short history in the health care delivery system. However, in this short period of time they have gained the respect of many health professionals and of their patients (Scherer, Bruce, & Runkawatt, 2007). Recently, television and lay publications have featured NPs and the significant contributions they are making to improving health. New areas of practice and settings for NPs continue to arise. In many instances, NPs have succeeded in caring for persons in rural areas, in inner cities, and for other vulnerable groups. NPs have established themselves as an integral part of the health care system. Nurse-Midwives Nurse-midwives are unique among APRNs because they are educated in two different professions. Midwifery is a profession in its own right; nursing is not a prerequisite to midwifery in many countries around the world. The American College of Nurse-Midwives (ACNM, 2004a) defines CNMs as individuals educated in the two disciplines of midwifery and nursing who complete a graduate degree program accredited by the Accreditation Commission for Midwifery Education (ACME) and pass the national certification examination of the American Midwifery Certification Board (AMCB). According to the ACNM (2004a), midwifery as practiced by CNMs and certified midwives (CMs) encompasses a full range of primary health care services for women from adolescence beyond menopause. These services include the independent provision of primary care, gynecologic and family planning services, preconception care, care during pregnancy, childbirth and the postpartum period, care of the normal newborn during the Blair_72518_PTR_01_001-026_03-20-15.indd 11 20/03/15 12:53 PM

12 I Foundations of Advanced Nursing Practice first 28 days of life, and treatment of male partners for sexually transmitted infections. Midwives provide initial and ongoing comprehensive assessment, diagnosis and treatment. They conduct physical examinations; prescribe medications including controlled substances and contraceptive methods; admit, manage and discharge patients; order and interpret laboratory and diagnostic tests and order the use of medical devices. Midwifery care also includes health promotion, disease prevention, and individualized wellness education and counseling. These services are provided in partnership with women and families in diverse settings such as ambulatory care clinics, private offices, community and public health systems, homes, hospitals and birth centers. (p. 1) Although the focus of midwifery care has historically been prenatal care and managing labor and birth, nurse-midwives are primary care providers for essentially healthy women. Nurse-midwives strongly believe in supporting natural life processes and not using medical interventions unless there is a clear need. This belief and others are reflected in the 2004 ACNM (2004b, p. 1) philosophy statement, which states that every person has a right to: • Equitable, ethical, accessible, quality health care that promotes healing and health • Health care that respects human dignity, individuality, and diversity among groups • Complete and accurate information to make informed health care decisions • Self-determination and active participation in health care decisions • Involvement of a woman’s designated family members, to the extent desired, in all health care experiences Midwives also believe in: • Watchful waiting and nonintervention in normal processes • Appropriate use of interventions and technology for current or potential health problems • Consultation, collaboration, and referral with other members of the health care team as needed to provide optimal health care (ACNM, 2004b) Midwifery is a very old profession, mentioned in the Bible. The practice of midwifery declined in the 18th and 19th centuries, and obstetrics developed as a medical specialty. In 1925, Mary Breckinridge established the Frontier Nursing Service (FNS) in Kentucky and was the first nurse to practice as a nurse-midwife in the United States. She received her midwifery education in England and returned to the United States with other British nurse-midwives to set up a system of care similar to that which she Blair_72518_PTR_01_001-026_03-20-15.indd 12 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 13 had observed in Scotland. The FNS was begun to care for individuals who were without adequate health care. The nurse-midwives of the FNS provided maternal and infant care and effectively demonstrated quality care and significantly improved outcomes. The first U.S. nurse-midwifery education program was started at the Maternity Center Association, Lobenstein Clinic, in New York City in 1932. The American College of Nurse-Midwives was incorporated in 1955. Nursemidwifery practice grew slowly until the late 1960s and early 1970s, when the profession experienced increased acceptance and consumer demand increased for nurse-midwives and the kind of care they provided (Varney, 2015). There are more than 13,000 CNMs/CMs in the United States, and in 2012, they attended 313,846 births, or 7.9% of all births, 11.8% of vaginal births, and 30.4% of all out-of-hospital births in the United States (ACNM, 2014a). Nurse-midwives have direct third-party reimbursement and prescriptive authority in all 50 states (ACNM, 2014b). In the 1970s, national accreditation of nurse-midwifery education programs and national certification of nurse-midwives was begun by ACNM. The ACME accreditation process is recognized by the U.S. Department of Education, and the certification process now conducted by the AMCB is recognized by the National Commission of Health Certifying Agencies. The ACNM document, Core Competencies for Basic Midwifery Practice (ACNM, 2012), describes the skills and knowledge that are fundamental to the practice of a new graduate of an ACME-accredited education program. These competencies guide curricular development in midwifery programs and are used in the nationally recognized accreditation process. Competencies described in the document include professional responsibilities; the midwifery management process; and midwifery care of women, including primary care; preconception care; gynecologic care (including contraceptive methods); perimenopausal and postmenopausal care; prenatal, intrapartum, and postpartum care of the childbearing woman; and care of the newborn. Hallmarks of midwifery practice are also delineated. Nurse-midwifery education began with certificate programs and has progressed to graduate education. There are presently 38 ACMEaccredited programs in the United States. Most midwifery programs are in schools of nursing, but two are in university-based health-related professions schools. A direct-entry (nonnursing) route to midwifery education, using the same nationally recognized accreditation and certification standards, began in 1997 at the State University of New York (downstate campus). CM students are required to complete certain prerequisite health sciences courses, such as chemistry, biology, nutrition, and psychology, before beginning midwifery education. In addition, certain knowledge and skills common in nursing practice are required before beginning the midwifery clinical courses in the program (ACME, 2005). CMs are currently authorized to practice in five states (ACNM, 2014a). Certified professional midwives (CPMs), another category of direct-entry midwives who attend Blair_72518_PTR_01_001-026_03-20-15.indd 13 20/03/15 12:53 PM

14 I Foundations of Advanced Nursing Practice out-of-hospital births, are recognized in approximately half of the states and have a different scope of practice and regulation process than midwives who graduate from ACME-accredited programs. Nurse-midwives in the United States have consistently demonstrated that their care results in excellent outcomes and client satisfaction among all women, including the large proportion of underserved, uninsured, lowincome, minority, and otherwise vulnerable women for whom CNMs provide care. Births attended by CNMs and CMs occur primarily in hospitals; more than 98% of births in the United States occurred in hospitals in 2012, although the number of home and freestanding birth center births has been rising (MacDorman, Mathews, & Declercq, 2014). Past researchers have demonstrated fewer interventions, including lower caesarean birth rates, among CNM-attended births versus physician-attended births, as well as outcomes at least comparable to physician-attended births (Blanchette, 1995; MacDorman & Singh, 1998; Rosenblatt et al., 1997). A systematic review and meta-analysis of midwifery care globally demonstrated that women receiving midwifery-led care experienced equivalent or better outcomes—including fewer episiotomies, less anesthesia use, reduced likelihood of preterm birth, and more spontaneous vaginal births—than those receiving other types of care (Sandall, Soltani, Gates, Shennan, & Devane, 2013). Another systematic review identified exclusively U.S.-based studies and found similar results, with equivalent or superior outcomes in initiating breastfeeding, operative and cesarean births, and perineal lacerations (Newhouse et al., 2011). From a policy perspective, midwifery care can be a cost-effective and sustainable approach to meeting society’s women’s health care needs (Renfew et al., 2014). Over the nearly 90-year history of nurse-midwifery/midwifery in the United States, a strong base of support documented by research has been developed and is ongoing. The number of educational programs and practitioners has grown substantially. The passage of the Patient Protection and Affordable Care Act in 2010 resulted in a key provision sought by CNMs for nearly 20 years: the same reimbursement as physicians under Medicaid for providing the same service (Bradford, 2013). During this era of health care reform, as health care dollars continue to be carefully allocated and specific outcomes measured more closely, CNMs and certified midwives can be expected to play a more prominent role in providing quality primary health care to women. Clinical Nurse Specialists CNSs are leaders and experts in evidence-based nursing practice (National Association of Clinical Nurse Specialists [NACNS], 2014). They are registered professional nurses with graduate preparation earned at the master’s or doctoral level. They may also be educated in a postmaster’s program that prepares graduates to practice in specific specialty areas (Lyon, 2004; Lyon & Minarik, 2001). In 2000, 183 schools offered CNS master’s programs, an increase from 147 programs in 1997 (Dayhoff & Lyon, 2001). The NACNS Blair_72518_PTR_01_001-026_03-20-15.indd 14 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 15 has developed curriculum recommendations for CNS education (NACNS, 2011) as well as competencies to reflect the Essentials of Doctoral Education for Advanced Nursing Practice (NACNS, n.d.). CNSs have traditionally worked in hospitals, but they now practice in many settings, including nursing homes, schools, home care, and hospice. NACNS’s essential characteristics and essential core content for CNS programs are based on CNSs’ spheres of influence: patients/clients and patients, nurses and nursing practice, and organizations/systems. The CNS role has had a long history in the United States. The CNS role was developed after World War II. Before that time, specialization for nurses was in the functional areas of administration and education. Recognizing the need to have highly qualified nurses directly involved in patient care, the concept of clinical nurse specialists emerged. Reiter (1966) first used the term nurse clinician in 1943 to designate a specialist in nursing practice. The first master’s program in a clinical nursing specialty was developed in 1954 by Hildegard E. Peplau at Rutgers University to prepare psychiatric clinical nurse specialists. That program launched the CNS role that has been an important player in the nursing profession and health care arena ever since, although the role has not been without controversy. Health care restructuring and cost-cutting initiatives in the 1980s and 1990s resulted in a loss of CNS positions in the United States. However, after increasingly frequent reports of adverse events in hospital settings in the 1990s (IOM, 1999; IOM Committee on the Quality of Health Care in America, 2001), it became apparent that CNSs were critical to obtaining quality patient outcomes (Clark, 2001; Heitkemper & Bond, 2004), with the result that CNSs are again seen as valuable professionals in many U.S. health care systems. As with the NP movement, the availability of federal funds for graduate nursing education programs and the Professional Traineeship Program through Health Resources and Services Administration (HRSA) that provides stipends for students have played a role in the development of many graduate CNS programs. The development and use of complex health care technology in the management of patients in hospitals and intricate surgical procedures has resulted in increasing acuity and complexity of patient care delivery. Thus, there is a need for nurses with advanced knowledge and expertise to be integrally involved in working with staff to assess, plan, implement, and evaluate care for these patients. Many hospitals have used CNSs as care coordinators and case managers in which they coordinate the care of patients with acute or chronic illnesses during their hospital stays and prepare them for discharge to their homes or other care facilities. CNSs have also been used as discharge planners working with staff to plan posthospital care for patients who have complex health problems (Naylor et al., 1994; Neidlinger, Scroggins, & Kennedy, 1987). Their importance in care coordination over the care continuum is only now being lauded, exemplified in the work of Naylor and colleagues, who reported that use of gerontologic CNSs as discharge planners resulted in fewer readmissions of elderly cardiac patients. Blair_72518_PTR_01_001-026_03-20-15.indd 15 20/03/15 12:53 PM

16 I Foundations of Advanced Nursing Practice Since its inception, the CNS role has suffered from role ambiguity (Rasch & Frauman, 1996; Redekopp, 1997). Although the initial vision was for CNSs to be integrally involved in patient care for a specific patient population, they have assumed many other roles, such as staff and patient educators, consultants, supervisors, project directors, and more recently, case managers. Redekopp noted that it is difficult for CNSs to precisely describe their roles to others because their roles are continually evolving to meet the health needs of a changing patient population in an everchanging health care system. Role ambiguity has made it difficult to measure the impact that CNSs have on patient outcomes. Thus, when budgetary crises have occurred in hospitals, CNSs have frequently had to advocate strongly to maintain their positions because outcome data to support the positive impact of their practice have either not been readily available or simply did not exist. There are numerous CNS specialties and subspecialties: psychiatric/ mental health nursing, adult health, gerontology, oncology, pediatrics, cardiovascular, neuroscience, rehabilitation, pulmonary, renal, diabetes, and palliative care, to name a few. Numerous organizations offer certification examinations for CNSs. However, some organizations do not specify that master’s degrees are required for certification in the specialty, causing confusion regarding the regulation and title of clinical nurse specialist. In the past, many CNSs have not sought third-party reimbursement, so they have not taken specialty CNS certification examinations. With changes in state nursing practice acts and the increase in third-party payment and prescriptive privileges for APRNs, the number of certified CNSs is now increasing. Controversy regarding CNS certification continues, however, because the examinations are not available in the many specialties that CNSs perform. Exemptions from state laws and regulations for CNSs have been provided by some states because of this lack of certification. To address this need, a core CNS certification examination is under development by the ANCC. In the late 1980s and early 1990s, many discussions and debates took place around the merging of the CNS and NP roles (Page & Arena, 1994). Several studies were conducted comparing the knowledge and skills of these two advanced practice roles (Elder & Bullough, 1990; Fenton & Brykczynski, 1993; Forbes, Rafson, Spross, & Kozlowski, 1990; Lindeke, Canedy, & Kay, 1996). Research indicated that there were many similarities in the educational preparation of these two groups of APRNs. Many CNSs viewed the proposed merger as the demise of the CNS role. NPs were concerned that they would need to abandon the title of NP, a title that had become familiar to many patients and health professionals. A new organization, the NACNS, was formed to assist CNSs and to provide a vehicle to publicize the many contributions that CNSs have made and continue to make in providing quality patient care. The CNS role today is a dynamic and needed advanced practice nursing role, and many in the nursing profession anticipate that it will continue to exist for years to come. Blair_72518_PTR_01_001-026_03-20-15.indd 16 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 17 Certified Registered Nurse Anesthetists Nurse anesthesia practice traces its origins to the inception of surgical anesthesia, a major innovation that allowed for the development of surgery as a means of treatment for disease. Anesthesia in the late 1800s was hazardous and crude. There was not a good understanding of the pharmacologic and physiologic effects of anesthetic drugs, primarily diethyl ether and chloroform. These anesthetics were often delivered in a “careless manner” by a surgical resident fresh out of medical school who had little or no training in the effects of the anesthetic (Bankert, 1989, p. 22). This led to disastrous results for patients. Thus, some surgeons turned to religious Hospital Sisters who would devote their entire attention to the well-being of the patient during the delivery of the anesthetic. One of the Hospital Sisters, Sister Mary Bernard, was the first identified nurse that delivered anesthesia at St. Vincent’s Hospital in Erie Pennsylvania in 1877 (Bankert, 1989). The practice of utilizing nurses to deliver anesthesia spread rapidly through the Catholic and secular hospitals of the late 1800s and early 1900s. In 1912, a formal program of training in the delivery of anesthesia for nurses was developed in Springfield, Illinois, by Mother Magdalene Wiedlocher of the Third Order of the Hospital Sisters of St. Frances. This order of Hospital Sisters went on to establish St. Mary’s Hospital in Rochester, Minnesota, that we now know as the origin of the Mayo Hospitals. These nurse anesthetists at St. Mary’s Hospital became known as experts in the delivery of anesthesia who devoted their full attention and skill to the well-being of the patient receiving anesthesia. One nurse anesthetist in particular, Alice Magaw, stood out as an example of the diligent care delivered by nurse anesthetists. In addition to skillfully delivering anesthetics, Magaw recorded her work and published it in respected medical journals of the time. One such paper published in 1906 documented 14,000 anesthetics at St. Mary’s Hospital “without a death directly attributable to anesthesia” (Bankert, 1989, p. 31). Magaw’s legacy is honored in the motto of the American Association of Nurse Anesthetists (AANA): Safe and effective anesthesia care (AANA, n.d.-b). Certified Registered Nurse Anesthetists (CRNAs) are registered nurses who have become anesthesia specialists by taking a graduate curriculum which focuses on the development of clinical judgment and critical thinking. They are qualified to make independent judgments concerning all aspects of anesthesia care based on their education, licensure, and certification. CRNAs are legally responsible for the anesthesia care they provide and are recognized in state law in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands. (AANA, 2010) Anesthesia care is delivered in collaboration with surgeons, podiatrists, dentists, radiologists, psychiatrists, cardiologists, and anesthesiologists in outpatient, inpatient, and office-based settings. Blair_72518_PTR_01_001-026_03-20-15.indd 17 20/03/15 12:53 PM

18 I Foundations of Advanced Nursing Practice The CRNA scope of practice includes comprehensive anesthesia and pain care across the lifespan in many different settings. The scope includes: 1. Performing and documenting a preanesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, and administering preanesthetic medications and fluids; and obtaining informed consent for anesthesia. 2. Developing and implementing an anesthetic plan. 3. Initiating the anesthetic technique which may include: general, regional, local, and sedation. 4. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring modalities for continuous evaluation of the patient’s physical status. 5. Selecting, obtaining, and administering the anesthetics, adjuvant and accessory drugs, and fluids necessary to manage the anesthetic. 6. Managing a patient’s airway and pulmonary status using current practice modalities. 7. Facilitating emergence and recovery from anesthesia by selecting, obtaining, ordering, and administering medications, fluids, and ventilatory support. 8. Discharging the patient from a postanesthesia care area and providing postanesthesia follow-up evaluation and care. 9. Implementing acute and chronic pain management modalities. 10. Responding to emergency situations by providing airway management, administration of emergency fluids and drugs, and using basic or advanced cardiac life support techniques. (AANA, 2010b) The CRNA may also have other responsibilities that could include administration and management activities, education, research, quality improvement, interdepartmental liaison, committee appointments, and oversight of other non-anesthesia departments. Nurse anesthesia educational programs are offered at both the master’s level and the clinical doctoral level. The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is the entity that accredits all nurse anesthesia educational programs regardless of the degree offered. This formal process of accreditation began in 1952 (Bankert, 1989). At this time, nurse anesthesia programs at the master’s degree level are a minimum of 24 months in length and at the doctoral level, a minimum of 36 months. All nurse anesthesia educational programs must provide a minimum number of cases and a minimum curriculum that includes pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 hours); anatomy, physiology, and pathophysiology (135 hours); professional aspects of nurse anesthesia practice (45 hours); basic and advanced principles of anesthesia practice including physics, equipment, technology and pain management (105 hours); research (30 hours); and clinical correlation conferences (45 hours); radiology; and Blair_72518_PTR_01_001-026_03-20-15.indd 18 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 19 ultrasound. In addition, the curriculum must include three (3) separate comprehensive graduate level courses in advanced physiology/ pathophysiology, advanced health assessment, and advanced pharmacology. Students must administer a minimum of 550 clinical cases that prepare them for the full scope of practice in a variety of clinical settings (COA, 2014). Completion of the nurse anesthesia educational program and the required cases qualifies the student to sit for the national certification examination (NCE). Following publication of the America Association of Colleges of Nursing’s initiative to move education of advanced practice nursing into doctoral frameworks by 2015, the AANA established a task force on doctoral education for nurse anesthetists in 2005. The task force recommended to the Board of Directors of the AANA that all nurse anesthesia educational programs be offered in a clinical doctoral framework by the year 2025 (AANA, 2007). The COA will not consider any new master’s degree programs for accreditation beyond 2015. Students accepted into an accredited program on January 1, 2022, and thereafter must graduate with doctoral degrees (COA, 2014). Unlike other nursing advanced practice specialties, nurse anesthesia programs are not necessarily housed in schools of nursing. Of the 113 programs of nurse anesthesia accredited in the United States, 47 (42%) are in a variety of non-nursing academic units (COA Annual Report, 2013). These programs may offer the Doctorate of Nurse Anesthesia Practice (DNAP) degree. Wherever the educational program is housed, all nurse anesthesia educational programs must be accredited through the COA and the graduates must pass the national certification examination. Thus the public is assured that every nurse anesthetist has met a set of predetermined qualifications for entry into practice. In 1986, the passage of the Omnibus Budget Reconciliation Act marked nurse anesthetists as the first group of advanced practice nursing professionals to be granted direct reimbursement for anesthesia and pain management services to Medicare enrollees. This paved the way for entrepreneurship and innovative practice settings for nurse anesthetists. In the 2013 AANA Practice Survey, 23.4% of respondents identified themselves as “independent contractors” (AANA, 2013). Furthermore, in 2001 the Center for Medicare and Medicaid Services (CMS) published its anesthesia care rule granting state governors the ability to opt out of the federal physician supervision requirement, thus allowing nurse anesthetists to work in collaboration with other healthcare providers without physician supervision (AANA, 2001). To date, 17 states have opted out of the CMS requirement for physician supervision of nurse anesthetists. In a recent study in the journal Health Affairs compared outcomes in states with physician supervision and those opt-out states. No harm was found when CRNAs delivered anesthesia without physician supervision (Dulisse & Cromwell , 2010). Nurse anesthesia practice is remarkably varied and flexible. Nurse anesthetists function in fast paced trauma team settings in urban areas and in highly independent rural settings. Nurse anesthetists provide critically needed surgical and obstetric anesthesia, acute pain management, trauma Blair_72518_PTR_01_001-026_03-20-15.indd 19 20/03/15 12:53 PM

20 I Foundations of Advanced Nursing Practice stabilization, and, in some instances, chronic pain management for the rural communities they live in. Without the services of nurse anesthetists, many of these small rural hospitals would close (Siebert, Alexander, & Lupien, 2003) . Nurse anesthetists have served in the military in peace and on the battlefield in every armed conflict since the World War I, including the most recent conflicts in Iraq and Afghanistan (AANA, 2010a). Nurse anesthetists are a crucial part of the modern health care system today both in terms of quality of care and access to highly skilled affordable care. The education and training of nurse anesthetists position these advanced practice nurses to lead healthcare into the future. INTERNATIONAL Although the content in this chapter has focused on APNs in the United States, it is encouraging to see the continuing development of these roles in other countries. Midwifery, a profession often distinct from nursing, has a longer history internationally than in the United States. The International Confederation of Midwives, so named in 1954, has more than 116 midwifery organization members representing 102 countries (see www.internationalmidwives.org). The recent Lancet Series on Midwifery (2014) highlighted midwifery as " a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants, in all countries" (Renfrew, 2014). Clinical specialization in nursing has existed in many countries for a very long time. For example, in the United Kingdom the NP role developed dramatically during the 1990s once the National Health Services recognized its legitimacy (Reverly, Walsh, & Crumbie, 2001). However, in other countries APNs are only beginning to develop programs and practices (Wang, Yen, & Snyder, 1995). CONCLUSION APRNs have made significant contributions to quality health care, particularly for vulnerable populations. If all Americans are to receive quality, cost-effective health care, it is critical that greater use be made of APRNs. Their advanced knowledge and skills, both in nursing and related fields make valuable contributions to the current and future health care system, especially in the task of meaningful health care reform. As the United States becomes more diverse, APRNs play key roles in providing culturally competent care. They assume leadership in developing new practice sites and innovative systems of care to enhance health care outcomes. A bright future awaits nursing and APRNs. Acknowledgment The author acknowledges the contributions of Mary Zwygart-Stauffacher, who contributed to this chapter in a previous edition. Blair_72518_PTR_01_001-026_03-20-15.indd 20 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 21 REFERENCES Accreditation Commission for Midwifery Education. (2005). The knowledge, skills, and behaviors prerequisite to midwifery clinical coursework. Washington, DC: Author. Advanced Practice Registered Nurses Consensus Workgroup & APRN Joint Dialogue Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification, and education. Retrieved from http://www.aacn. nche .edu/Education/pdf/APRNReport.pdf American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author. Retrieved from http://www.aacn.nche.edu/DNP/pdf7Essentials.pdf American Association of Colleges of Nursing. (2011). The essentials of master’s education for advanced practice nursing. Washington, DC: Author. American Association of Colleges of Nursing. (2014). Doctor of nursing practice programs. Retrieved from http://www.aacn.nche.edu/media-relations/factsheets/dnp American Association of Nurse Anesthetists. (n.d.-a). Certified registered nurse anesthetists at a glance. Retrieved June 30, 2014, from http://www.aana.com/ ceandeducation/becomeacrna/Pages/Nurse-Anesthetists-at-a-Glance. aspx. American Association of Nurse Anesthetists. (n.d.-b). Who we are. Retrieved June 30, 2014, from http://www.aana.com/aboutus/Pages/Who-WeAre.aspx. American Association of Nurse Anesthetists. (2001). Iowa becomes first state to opt out of federal anesthesia requirement. Retrieved June 30, 2014, from http:// www.aana.com/newsandjournal/News/Pages/121301-Iowa-Becomes-theFirst-State-to-Opt-Out-of-Federal-Anesthesia-Requirement.aspx. American Association of Nurse Anesthetists. (2007). AANA position on doctoral preparation of nurse anesthetists. Retrieved June 30, 2014, from http://www. aana.com/myaana/AANABusiness/professionalresources/Documents/dtf_ posstatemt0707.pdf. American Association of Nurse Anesthetists. (2010a). History of nurse anesthesia practice. Retrieved June 30, 2014, from http://www.aana.com/aboutus/ Documents/historynap.pdf. American Association of Nurse Anesthetists. (2010b). CRNA scope of practice. Retrieved May 28, 2014, from http://www.aana.com/aboutus/Documents/ scopeofpractice.pdf. American Association of Nurse Practitioners. (2013). NP facts. Retrieved from http://www.aanp.org/images/documents/about-nps/npfacts.pdf American College of Nurse-Midwives (2004a). Definition of midwifery practice. Washington, DC: Author. American College of Nurse-Midwives. (2004b). Philosophy of the American College of Nurse-Midwives. Washington, DC. Author. American College of Nurse-Midwives. (2012). Core competencies for basic midwifery practice. Washington, DC: Author. American College of Nurse-Midwives. (2014a). CNM/CM-attended birth statistics in the United States. Washington, DC: Author. American College of Nurse-Midwives. (2014b). Essential facts about midwives. Washington, DC: Author. Blair_72518_PTR_01_001-026_03-20-15.indd 21 20/03/15 12:53 PM

22 I Foundations of Advanced Nursing Practice American Nurses Association. (2010). Nursing: Scope and standards of practice. Washington, DC: Author. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements (2nd ed.). Washington, DC: Author. American Nurses Association, National Association of Pediatric Nurses Practitioners, & Society of Pediatric Nurses. (2010). Pediatric nursing: Scope and standards of practice. Washington, DC: American Nurses Association. Bankert, M. (1989). Watchful care: A history of America’s nurse anesthetists. New York, NY: Continuum. Benner, P (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Blanchette, H. (1995). Comparison of obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives and a private practice group of obstetricians in the same community. American Journal of Obstetrics & Gynecology, 172(6), 1868–1871. Bradford, H. M. (2013). Women’s health and maternity care policies: Current status and recommendations for change. In M. D. Avery (Ed.), Supporting a physiologic approach to pregnancy and birth: A practical guide. Ames, IA: Wiley-Blackwell. Brown, S., & Grimes, D. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary care. Nursing Research, 44, 332–339. Brykczynski, K. (1989). An interpretive study describing the clinical judgment of nurse practitioners. Scholarly Inquiry for Nursing Practice: An Interpretive Journal, 3, 113–120. Clark, A. (2001). What will it take to reduce errors in health care settings? Clinical Nurse Specialist, 15(4), 182–183. Council on Accreditation of Nurse Anesthesia Educational Programs. (2004). Standards for accreditation of nurse anesthesia educational programs, Revised May 2014. Retrieved June 30, 2014, from http://www.aana.com/myaana/ Accreditation/Documents/Standards%20for%20Accreditation%20of% 20Nurse%20Anesthesia%20Education%20Programs%20_May%202014. pdf. Council on Accreditation of Nurse Anesthesia Educational Programs. (2013). Nurse anesthesia programs summary of 2013 annual report data. Retrieved June 30, 2014, from http://www.aana.com/myaana/Accreditation/ Documents/Summary%20of%20COA%20Annual%20Report%20Data%20 2013.pdf. Dayhoff, N., & Lyon, B. (2001). Assessing outcomes of clinical nurse specialist practice. In R. Kleinpell (Ed.), Outcome assessment in advanced nursing (pp. 103–129). New York, NY: Springer Publishing. Dracup, K. (2004). Peterson’s nursing programs. Retrieved from http://www. petersons.com/nursing/articles/masters.asp?sponsor = 1 Dulisse, B, & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs 29(8), 1469–1475. Edwardson, S. (2004). Matching standards and needs in doctoral education in nursing. Journal of Professional Nursing, 20, 40–46. Elder, R., & Bullough, B. (1990). Nurse practitioners and clinical nurse specialists: Are the roles merging? Clinical Nurse Specialist, 4, 78–84. Fenton, M. (1985). Identifying competencies of clinical nurse specialists. Journal of Nursing Administration, 15, 31–37. Blair_72518_PTR_01_001-026_03-20-15.indd 22 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 23 Fenton, M., & Brykczynski, K. (1993). Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. Journal of Professional Nursing, 9, 313–326. Forbes, K., Rafson, J., Spross, J., & Kozlowski, D. (1990). Clinical nurse specialist and nurse practitioner core curricula survey results. Nurse Practitioners, 15, 45–48. Ford, L. (1979). A nurse for all settings: The nurse practitioner. Nursing Outlook, 27, 516–521. Ford, L. (2005). Opinions, ideas and convictions for NPs’ founding mother, Dr. Loretta Ford. The American Journal for Nurse Practitioners, 9(3), 31–33. Heitkemper, M., & Bond, E. (2004). Clinical nurse specialists: State of the profession and challenges ahead. Clinical Nurse Specialist, 18(3), 135–140. Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324(7341), 819–823. Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Institute of Medicine Committee on the Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Kapu, A., & Kleinpell, R. (2012). Developing nurse practitioner associated metrics for outcomes assessment. Journal of the American Academy of Nurse Practitioners, 1–8. doi:10.1111/1745-7599.12001 Klein, T. (2005). Scope of practice and the nurse practitioner: Regulation, competency, expansion, and evolution. Topic in Advanced Practice Nursing eJournal, 7(3), 1–10. Kopanos, T. (2014). Celebrating mile markers. The Journal for Nurse Practitioners, 10(7), A13, A14. Lindeke, L, Canedy, B., & Kay, M. (1996). A comparison of practice domains of clinical nurse specialists and nurse practitioners. Journal of Professional Nursing, 13, 281–287. Lyon, B. (2004). What to look for when analyzing clinical nurse specialist statutes and regulations. Clinical Nurse Specialist, 16(1) 33–34. Lyon, B., & Minarik, P. (2001). Statutory and regulatory issues for clinical nurse specialist (CNS) practice: Ensuring the public’s access to CNS services. Clinical Nurse Specialist, 15(3), 108–114. MacDorman, M. F. & Singh, G. K. (1998). Midwifery care, social and medical risk factors, and birth outcomes in the USA. Journal of Epidemiology and Community Health, 52(5), 310–317. MacDorman, M. F., Mathews, T. J., & Declercq, E. (2014). Trends in out-of-hospital births in the United States, 1990–2012. NCHS data brief, no. 144. Hyattsville, MD: National Center for Health Statistics. Martin, K. (2000). Nurse practitioners: A comparison of rural-urban practice patterns and willingness to serve in underserved areas. Journal of the American Academy of Nurse Practitioners, 12, 491–496. Mundinger, M., Kane, R., Lenz, E., Totten, A., Tsai, W., Cleary, P., …, Shelanski, M. L. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283, 59–68. National Association of Clinical Nurse Specialist (NACNS). (2011). Criteria for the evaluation of clinical nurse specialist master's, practice doctorate, and post-graduate Blair_72518_PTR_01_001-026_03-20-15.indd 23 20/03/15 12:53 PM

24 I Foundations of Advanced Nursing Practice certificate educational programs. Retrieved from http://www.nacns.org/docs/ CNSEducationCriteria.pdf National Association of Clinical Nurse Specialists. (n.d.). Organizing framework and CNS core competencies. Retrieved from http://www.nacns.org/docs/ CNSCoreCompetencies.pdf National Association of Clinical Nurse Specialists. (2014). What is a clinical nurse specialist? Retrieved from http://www.nacns.org/html/cns-faqs1.php National Center for Health Statistics. (2006). Births: Final data for 2006. Report available from National Center for Vital Statistics (Report No. 57-7). Hyattsville, MD: Author. National Council of State Boards of Nursing. (2002). Regulation of advanced practice nursing. Retrieved from http://www.ncsbn.org National Organization of Nurse Practitioner Faculties. (1995). Advanced nursing practice: Curriculum guidelines and program standards for nurse practitioner education. Washington, DC: Author. National Organization of Nurse Practitioner Faculties. (2006). 2006 domains and core competencies of nurse practitioner practice. Washington, DC: Author. Retrieved from http://www.nonpf.org/NONPF2005/CoreCompsFINAL06. pdf National Organization of Nurse Practitioner Faculties. (2012). Nurse practitioner competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/ resource/resmgr/competencies/npcorecompetenciesfinal2012.pdf National Organization of Nurse Practitioner Faculties. (2013). Population focused nurse practitioner competencies: Family/across the lifespan, neonatal, pediatric acute care, pediatric primary care, psychiatric mental health and women’s health/ gender related. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/ resource/resmgr/competencies/populationfocusnpcomps2013.pdf Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120, 999–106. Neidlinger, S., Scroggins, K., & Kennedy, L. (1987). Cost evaluation of discharge planning for hospitalized elderly. Nursing Economics, 5, 225–230. Newhouse, R. P., Stanik-Hutt, J., White, K. M, Johantgen, M., Bass, E. B., Zangaro, G., …, Weiner, J. P. (2011). Advanced practice nursing outcomes 1990–2008: A systematic review. Nursing Economics, 29, 230–250. Nurse Practitioner Roundtable. (2008). Nurse practitioner DNP education, certification and titling: A unified statement. Washington, DC: Author. Page, N., & Arena, D. (1994). Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles. Image: The Journal of Nursing Scholarship, 26, 315–318. Rasch, R., & Frauman, A. (1996). Advanced practice in nursing: Conceptual issues. Journal of Professional Nursing, 12, 141–146. Redekopp, J. (1997). Clinical nurse specialist role confusion: The need for identity. Clinical Nurse Specialist, 11, 87–91. Reiter, F. (1966). The nurse clinician. American Journal of Nursing, 66, 274–280. Renfrew, M. J., Homer, C. S. E., Downe, S., McFadden, A., Muir, N., Prentice, T., & ten Hoope-Bender, P. (2014). Executive Summary. The Lancet Series on Midwifery, 384, 1–8. Blair_72518_PTR_01_001-026_03-20-15.indd 24 20/03/15 12:53 PM

1 Overview of Advanced Practice Registered Nursing 25 Reverly, S., Walsh, M., & Crumbie, A. (2001). Nurse practitioners: Developing the role in hospital settings. Oxford, UK: Butterworth Heinemann. Rosenblatt, R., Dobie, S., Hart, L., Schneeweiss, R., Gould, D., Raine, T. R., …, Perrin, E. B. (1997). Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health, 87, 344–351. Safriet, B. (1998). Still spending dollars, still searching for sense: Advanced practice nursing in an era of regulatory and economic turmoil. Advanced Practice Nursing Quarterly, 4, 24–33. Sandall, J., Soltani, H., Gates, S., Shennan A., & Devane, D. (2013). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. Aug 21;8:CD004667. Scherer, Y. K., Bruce, S. A., & Runkawatt, V. (2007). A comparison of clinical simulation and case study presentation on nurse practitioner students’ knowledge and confidence in managing a cardiac event. International Journal of Nursing Education, 4(1), 1–14. Siebert, E., Alexander, J., & Lupien, A. (2004). Rural nurse anesthesia practice: A pilot study. AANA Journal, 72(3), 181–190. Retrieved June 30, 2014, from http://www.aana.com/newsandjournal/Documents/181-190.pdf. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2014). Highlights From the 2012 National Sample Survey of Nurse Practitioners. Rockville, Maryland: U.S. Department of Health and Human Services. Varney, H. (2015). Varney’s midwifery. Boston, MA: Jones & Bartlett. Blair_72518_PTR_01_001-026_03-20-15.indd 25 20/03/15 12:53 PM

Blair_72518_PTR_01_001-026_03-20-15.indd 26 20/03/15 12:53 PM

The most important word in the title of advanced practice registered nurse (APRN) is the last one: nurse. Advanced education enables nurses to expand their knowledge base and expertise in nursing so that their practices differ not only from those of nurses with an associate’s or bachelor’s degree but also from those of other health professionals, particularly physicians or physician assistants. Nurses often underestimate the profound positive effect that their care can have on improving individual and population outcomes and the impact on quality of care. Florence Nightingale, in Notes on Nursing (1859/1992), noted that people in her day often thought of nursing as signifying “little more than the administration of medicines and the application of poultices” (p. 6). Efforts are still necessary to convey the full scope of nursing practice to other professionals and to the public so that nurses’ contributions to positive health outcomes are understood, respected, valued, and reimbursed. So often the media have focused on the physical assessment skills, tasks, and prescriptive privileges of APRNs rather than on the distinctive and unique knowledge, education, abilities, and expertise that characterize advanced practice registered nursing practice. As advanced practice nursing moves rapidly toward the practice doctorate as entry into practice, an excellent opportunity exists to reconceptualize how advanced practice nursing is taught in APRN programs. Burman et al. (2009) challenge educators to focus on health promotion and disease management, incorporating theories from a variety of disciplines to improve health behavior and change their pedagogies as doctorate of nursing practice (DNP) programs and curricula continue to develop. Chism (2013) supports the need for DNP curricula to focus on the leadership of chronic disease management and the care of our aging population. 27 2 Gail B. Katz ADVANCED PRACTICE WITHIN A NURSING PARADIGM Blair_72518_PTR_02_027-040_03-20-15.indd 27 20/03/15 12:53 PM

28 I Foundations of Advanced Nursing Practice WHAT IS NURSING? Definitions of Nursing For many years the nursing profession has sought to define nursing and to identify its scope of practice. It is critical that APRNs and those aspiring to this role have a clear understanding of what nursing is in order for them to provide a clear understanding of nursing’s unique contributions to health care outcomes in their interprofessional interactions. Therefore, several of the many definitions of nursing that have been put forth over the years are reviewed. Florence Nightingale (1859/1992) formulated one of the earliest definitions of nursing, which went beyond caring for ill patients. She emphasized the whole person, including diet and environment. The aim of nursing care, according to Nightingale, is to put the individual in the best possible condition so that nature can act upon the person. Nightingale’s Notes on Nursing, although written 150 years ago, speaks to the substantive basis of nursing. Not only does Nightingale elaborate on interventions nurses can employ, she also underscores the necessity of thorough assessments before planning nursing care. Reading Notes on Nursing should therefore be a part of every APRN curriculum. In Virginia Henderson’s (1966) definition of nursing, emphasis is placed on the nurse collaborating with the individual to enhance the individual’s health status. Henderson defined nursing as assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as soon as possible. (p. 15) Henderson’s definition contains many elements that constitute the substantive nature of nursing. Health promotion is a key component of her definition. In addition, the caring aspects of nursing are emphasized. Not all individuals will recover from their diseases or injuries. It is the nurse’s role to assist the individual to achieve the goals he or she has established. Myss (1996, 2004) noted in her well-known works on healing that in curing modalities the individual is passive, but she argues that the individual must take an active role to be healed. APRNs can play a key role in assisting individuals in their healing process because APRNs are able to bring additional expertise to these interactions and to perform holistic health assessments. Henderson stresses helping the individual gain independence. Independence is a Western belief and may not be a value in all cultures. Thus, it is important for the nurse to ascertain the personal values of each individual and realize that independence may not be one of their preferences. Nojima (1989), a Japanese nursing theorist, defined nursing practice as “a human activity carried out by nurses to help individuals organize their health conditions so that they are able to live optimally and realize their Blair_72518_PTR_02_027-040_03-20-15.indd 28 20/03/15 12:53 PM

2 Advanced Practice Within a Nursing Paradigm 29 potential” (pp. 6–7). In her definition, the focus is on a person’s quality of life. The partnership between the nurse and the individual is evident in Nojima’s definition of nursing. With the advent of globalization, it is important to review the characteristics of nursing outside of Western medicine (Nojima, Tomikana, Makabe, & Snyder, 2003). The American Nurses Association (ANA) has defined nursing as follows: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. (ANA, 2010, p. 10) Previously, the definition of nursing focused on persons and their responses to health problems, rather than specific illnesses. This definition of nursing developed in 2003, which emphasizes health promotion and optimal health, remains unchanged in current discussions of the ANA’s Social Policy Statement (ANA, 2010). The focus on health differentiates nursing from the practice of medicine. Despite the frequent reference to the ANA definition of nursing, many APRNs have encountered difficulty practicing from a nursing model. They have been seemingly forced to launch their practice within the medical model in part because of medical diagnoses used for billing and coding and in part because of the medical community’s and the public’s perception of APRNs. Although it is important to know the cause of a person’s pain or stress, much of nursing care remains the same despite the cause. It has been encouraging to see the Agency for Healthcare Research and Quality (AHRQ) consider problems or responses, rather than disease entities, as the focus of practice guidelines. The AHRQ website (www.ahrq.gov) is an excellent resource for evidence-based practice and current clinical practices. Advanced practice nursing builds on the competence of the professional nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge (ANA, 2010). APRNs are prepared in one of the four roles: certified nurse-midwife, clinical nurse specialist, nurse practitioner, or certified registered nurse anesthetist. The APRN consensus model (2008) defines the APRN as a "provider that is certified in one of the four roles, educated in health promotion, assessment, diagnosis, management, pharmacotherapeutics, and direct care to individuals, populations, and communities" (Stanley, 2012, p. 244). Licensure, accreditation, certification, and education (LACE) should be consistent with role population (APRN Consensus Workgroup & APRN Joint Dialogue Group, 2008). Specialization within advanced practice focuses beyond the six populations (family/individual across lifespan, adult-gerontology, neonatal, pediatrics,women's health/gender related, psychiatric/mental health) and provides depth within a population. One of the most important aspects of specialization in nursing is that the distinct specialization is always a part of the whole field or discipline of professional nursing (ANA, 2010). Blair_72518_PTR_02_027-040_03-20-15.indd 29 20/03/15 12:53 PM

30 I Foundations of Advanced Nursing Practice The APRN consensus model, LACE has stipulations that APRNs be educated within an accredited program with advanced pathophysiology, advanced health assessment, advanced pharmacology—the three Ps; complete a minimum of 500 clinical hours; and be nationally certified. The licensure of an APRN is “defined as a legal title and credentials to be granted to all advanced practice registered nurses meeting the definitional criteria. Boards of nursing are responsible for granting a second license to APRNs in all four roles” (Stanley, 2011, p. 248). Rounds, Zych, and Mallary (2013) further state that the LACE model is not only relevant to the national movement of improving nursing regulation but has been shown to improve the professional transition for APRNs. Safety is once again emphasized as the primary motivator for national regulation of advanced nursing practice (Rounds et al., 2013). The ANA’s A Social Policy Statement (2010) emphasizes the characteristics of nursing practice to include human responses, theory application, evidence-based nursing actions, and outcomes. These characteristics build the foundation for professional nursing (ANA, 2010). Within this model, nursing’s professional scope of practice, code of ethics, specialization, and certification laid the base for professional nursing. Building on this base in a pyramid model are individual state’s nurse practice acts, rules, and regulations. From this level, institutional policies and procedures guide nursing practice, with self-determination as the top level of the pyramid model. This model lays the foundation not only for professional nursing but for all its expanded roles and specializations. Scope of Practice Gaining more knowledge about the substantive basis of nursing is an essential component of APRN education. Scope of practice can be viewed in several ways. In fact, findings from the numerous studies undertaken to identify, describe, and classify the phenomena of concern to nurses have helped clarify our understanding of scope of practice. One way to determine scope of practice from a regulatory framework is to focus on population, with each APRN working within his or her specific practice population and his or her actual practice is determined by the APRN regulatory model. Other initiatives delineate the substantive basis of nursing. Two of these initiatives—nursing diagnoses and human responses—will be discussed further. Nursing Diagnoses Nursing diagnoses are one strategy nurses have used to describe phenomena for which nurses provide care. Since the First Nursing Diagnosis Conference in 1973, nurses within the North American Nursing Diagnosis Association International (NANDA-I) have worked to identify, describe, and validate individual problems and concerns that fall within the domain of nursing. Currently there are 235 approved or revised nursing diagnoses (NANDA-I, 2015). Continued efforts are necessary Blair_72518_PTR_02_027-040_03-20-15.indd 30 20/03/15 12:53 PM

2 Advanced Practice Within a Nursing Paradigm 31 to identify and validate new diagnoses and to revise existing diagnoses. APRNs have provided and can continue to provide leadership in the nursing diagnosis movement. NANDA-I diagnoses are grouped under nine functional patterns: exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. According to Newman (1984), it is important for nurses to determine changes in an individual’s patterns. In approaching assessment in this manner, the focus is on the whole person rather than on specific diagnoses. Nursing diagnoses have been widely accepted not only in the United States but also internationally (NANDA-I, 2015). As the first effort to develop a common language for nursing phenomena, and despite numerous criticisms, using such diagnoses assists nurses in focusing on those aspects of care for which nursing interventions can be identified and nurse-sensitive outcomes can be determined. APRNs therefore need to be familiar with both nursing and medical diagnoses. In the United States, a number of projects to identify and classify nursing interventions have been initiated. The National Intervention Classification (NIC) has identified and classified more than 550 research-based nursing interventions (Bulechek, Butcher, Dochterman, & Wagner, 2013). A project identifying nursing outcomes links nursing diagnoses, nursing outcomes, and interventions (Johnson et al., 2005). Human Responses The ANA (2010) has delineated phenomena of concern to nursing. The identified phenomena were not meant to be exhaustive but rather exemplars of the types of concerns that fall within the purview of nursing. Human experiences and responses proposed by the ANA (2010) include promotion of health and wellness; promotion of safety and quality of care; care and self-care processes; physical, emotional, and spiritual comfort, discomfort, and pain; adaptation to physiologic and pathophysiologic processes; emotions related to the experience of birth, growth and development, health, illness, disease, and death; meanings ascribed to health and illness; linguistic and cultural sensitivity; health literacy; decision making and the ability to make choices; relationships, role performance, and change processes within relationships; social policies and their effects on health; health care systems and their relationships to access, cost, and quality of health care; and the environment and the prevention of disease and injury. As with nursing diagnoses, these identified human responses assist APRNs in focusing on the health concerns and needs for the individual, population, or communities. Advanced practice nursing care is of primary importance in producing positive individual outcomes while focusing on health promotion, disease management, education, and wellness. Therapeutics for managing the human responses or assisting the person in managing them transcends medical entities. For example, despite various causes for sleep problems, nursing interventions, such as massage and Blair_72518_PTR_02_027-040_03-20-15.indd 31 20/03/15 12:53 PM

32 I Foundations of Advanced Nursing Practice music therapy, can be used successfully. Viewing nursing in the context of, and the perspective of, human responses helps all nurses organize the plan of care content from the nurse’s point of view. THE ART AND SCIENCE OF NURSING The Art of Nursing The art of nursing is integrally tied to the caring aspect of nursing. For many years, nursing was defined as both an art and a science. As nurses began to give more attention to establishing a scientific basis for nursing practice, they thereby gained greater acceptance in the scientific community and the art or caring aspect of nursing received less attention. In practice settings, for example, nurses focused more attention on the high technology used in caring for individuals with complex health problems. Nonetheless, the public has sustained its attachment and desire for caring interventions, such as massage, therapeutic touch, listening, guided imagery, and aromatherapy, to name a few. A number of reasons for which people seek nonpharmacologic complementary therapies have been proposed: (a) they wish to be treated as a whole person by health professionals; (b) they wish to be active participants in their care; (c) they desire that the treatment not be worse than the disease; and (d) they feel that Western health care does not meet all of their needs. Therefore, it is important that APRNs consider how they can integrate the art of nursing, which includes traditional and nontraditional nursing interventions, into their practice. The essence of the APRN is the caring relationship with the patient. Through sharing knowledge and providing support through communication, caring, and relationship building, the APRN fosters health with patients and communities. Caring is a critical element of nursing practice. Leininger (1990), Watson (1988), and Gadow (1980) have each put forth definitions of caring. Watson defined the art of caring as a human activity consisting of the following: a nurse consciously, by means of certain signs, passes on to others feelings he or she has lived through, realized or learned; others are united to these feelings and also experience them. (p. 68) Newman, Sime, and Corcoran-Perry (1991) noted that the focus of nursing is “caring in the human health experience” (p. 3). The National Organization of Nurse Practitioner Faculties (NONPF) has identified patient- and family-centered care as a core competency (NONPF, 2012). Caring requires that a nurse be competent in assessing and intervening. Benner (1998) noted that a caring attitude was not sufficient to make an action a caring practice. The practice must be implemented in an excellent manner in order to be viewed as caring. Caring and the art of nursing convey very similar meanings, but caring nurses also seek the scientific basis for their practice and continue to update their expertise and Blair_72518_PTR_02_027-040_03-20-15.indd 32 20/03/15 12:53 PM

2 Advanced Practice Within a Nursing Paradigm 33 knowledge. APRNs possess the knowledge and ability to critique research about specific therapies and determine their applicability to specific individual populations. In 1993 Schoenhoefer and Boykin proposed that the nursing process– based care models, including nursing diagnoses, did not truly address what nurses ought to be doing. Their grand theory of nursing has a framework based on caring that is specific to each nurse, person, and situation, requiring personal individual knowledge of each patient, as well as including empirical knowledge of each patient’s situation. They acknowledge that all humans care and that nursing is a discipline that requires knowing and developing advanced nursing knowledge. Nursing is also a profession, in which nursing knowledge is applied and used in response to the individual’s human needs while still being a dynamic, evolving, creative, and caring process (Schoenhoefer & Boykin, 1993; Zaccagnini & Waud White, 2014). APRNs are well prepared to practice from a theorydriven human caring basis. A theory-based advanced nursing practice defines and exemplifies many attributes of the APRN. Hagedorn and Quinn (2004) proposed a theory of primary caring specific to the APRN that includes five domains: connection, consistency, commitment, community, and change. The domain connection describes the APRN’s effectiveness based on relationship-centered caring with the patient, family, and community. Consistency describes the importance of evidence- and theory-based care in advanced nursing practice. Commitment describes how the nurse practitioner (NP) is committed to serve each patient and family to his or her best ability. Community illustrates the role of the NP in facilitating full access to health care for all persons and strives to meet unmet community health needs. The fifth domain, change, explains how APRNs introduce innovative models of health care and share decision making with patients. Basic human needs are to be viewed as a whole person and cared for. It is the role of the APRN to support and assist the patient in being cared for in a holistic manner. APRNs incorporate the empiric aspects of medicine but practice within a nursing framework. The APRN’s qualities and actions of presence, empowerment, reflection, listening, touch, empathy, humor, and knowing the community, as well as the APRN’s ability to access care and to directly provide care, ensure patient satisfaction, and provide quality evidence-based outcomes (Hagedorn & Quinn, 2004). The Science of Nursing Significant progress has been made in developing the knowledge base that underlies nursing practice, revealing that nursing is characterized by both art and science (ANA, 2004). Although nursing is guided by standards of practice based on clinical evidence and research, additional research is always needed to further develop evidence-based practices so that APRNs will have a sound scientific basis from which to choose specific interventions for individuals or populations (ANA, 2010). The clinical guidelines Blair_72518_PTR_02_027-040_03-20-15.indd 33 20/03/15 12:53 PM

34 I Foundations of Advanced Nursing Practice developed by professional and governmental agencies—available through the National Guideline Clearinghouse—exemplify the work that has been done, and that continues to be done, in identifying “best practices" based on research findings. APRNs play a key role in helping nurses review research and develop clinical guidelines that incorporate existing knowledge bases. THEORETICAL AND CONCEPTUAL MODELS During the past 50 years, the nursing profession has given considerable attention to theoretical and conceptual models. This attention has served to differentiate nursing from other disciplines (Marrs & Lowry, 2009; Russell & Fawcett, 2005). However, nursing theories are not new in nursing. Nightingale (1859/1992) elaborated on the relationship of the environment to health and well-being. Numerous theoretical and conceptual models exist. What relevance do nursing theories have to practice? Can’t nurses merely practice nursing? Meleis (2011) noted that a theory articulates and communicates a mental image of a certain order that exists in the world. This image includes components, and these components inform a model or perspective that guides each nurse’s practice. This model may be identical to one of the publicized nursing theories, or it may be based on a theoretical perspective from another discipline. In some instances, eclectic models are used in which nurses combine elements from established nursing theories or theories from other disciplines. New nursing theories continue to be developed. Of particular importance is the delineation of nursing theories that incorporate various cultural perspectives, because the Western philosophical perspective to date has not pervaded many of the existing theories. There has been much discussion about whether one grand nursing theory is needed. Would the existence of a grand or meta-theory be advantageous to the progression of the profession and discipline? RiehlSisca (1989) stated that nursing has benefited from having a multiplicity of theories. The wide range of perspectives elaborated in these theories has helped nurses to more clearly define the nature of the discipline and profession, to evaluate various approaches that can be employed in practice, and to respect diversity as a positive element. Alligood and MarrinerTomey (2005) identified seven theorists who have developed primary grand theories or conceptual frameworks for nursing: Johnson (1980), King (1971), Levine (1967), Neuman (1974), Orem (1980), Rogers (1970), and Roy (1984). Many other nurses have developed midrange theories or conceptual frameworks that have served as a basis for research and practice. More recently, nurses have turned their attention to midrange theories. Midrange theories, which focus on a limited number of variables, are more amenable to empirical testing than are grand theories by definition. Examples of midrange theories include empathy (Olson & Hanchett, 1997), uncertainty in illness (Mishel, 1990), resilience (Polk, 1997), mastery (Younger, 1991), self-transcendence (Reed, 1991), caring (Swanson, 1991), and illness trajectory (Wiener & Dodd, 1993). Blair_72518_PTR_02_027-040_03-20-15.indd 34 20/03/15 12:53 PM

2 Advanced Practice Within a Nursing Paradigm 35 Duffy (2009) developed the quality-caring model, providing the APRN with a framework that emphasizes the less visible value of nursing—that is, caring. This is often the less obvious value, but one that guides practice, provides a foundation for quality care, improved outcomes, and patient satisfaction, and supports research. In her model, the evidence-based care environment in health care today is merged with the caring qualities and attributes of nursing. Caring values, attitudes, knowledge, and behaviors will guide and drive the process of the care plan and interventions, and will establish the foundation for strong relationships. The APRN patient–nurse relationship is primary and includes all interactions and interventions for which the APRNs are accountable and will implement autonomously. To be a successful APRN leader, collaborative relationships are necessary and include “those activities and responsibilities that nurses share with the members of the interprofessional healthcare team” (Duffy, 2009, p. 82). Many nurses give little thought to the tenets that guide their practice; however, these philosophical underpinnings have a profound impact on the nature and scope of their practice. When APRNs have a theory-guided practice, they improve the care being provided by offering structure, efficiency in regard to continuity of care, and higher quality of care and improved health outcomes. The discipline of nursing, including professionalism, accountability, and APRN autonomy as a care provider, is supported with a nursing theory–guided practice. Often, an APRN practices and applies clinical decision making within a nursing framework but is not consciously aware of doing so. Nurses have an ethical and moral responsibility to practice nursing with a consciously defined approach to care. The theoretical or conceptual model used by a nurse provides the basis for making the complex decisions that are crucial in the delivery of high-quality nursing care. In this regard, Smith (1995) stated the following: The core of advanced practice nursing lies within nursing’s disciplinary perspective on human-environment and caring interrelationships that facilitate health and healing. This core is delineated specifically in the philosophic and theoretic foundations of nursing. (p. 3) Thus, nursing theory is an important component of APRN education. Nursing is a practice discipline, and theories achieve importance in relation to their impact on nursing care. Recently, attempts have been made to relate nursing theories to practice and to begin testing these theories. However, only minimal testing of these theories in practice settings has occurred. The number of theoretical nursing studies, particularly studies examining the efficacy of nursing interventions, is an indication of the apparent separation of theories and practice that has characterized much of nursing practice. As DNP programs continue to mature and develop, it is anticipated that the application gap between theories and practice will narrow. Blair_72518_PTR_02_027-040_03-20-15.indd 35 20/03/15 12:53 PM

36 I Foundations of Advanced Nursing Practice The theoretical or conceptual framework that an APRN selects and uses has a major impact on the assessments that are made and the nature of the interventions that are chosen to achieve individual outcomes. Gordon (2007) and Johnson (1989) have noted the profound impact a nurse’s theoretical perspective can have on a nursing practice. Gordon (1987) stated the following: One’s conceptual perspective on clients and on nursing’s goals strongly determines what kinds of things one assesses. Everyone has a perspective, whether in conscious awareness or not. Problems can arise if the perspective “in the head” is inconsistent with the actions taken during assessment. Information collection has to be logically related to one’s view of nursing. (p. 69) A conceptual model provides the practitioner with a general perspective or a mind-set of what is important to observe, which in turn provides the basis for making nursing diagnoses and selecting nursing interventions. INCORPORATING NURSING INTO ADVANCED PRACTICE NURSING Guaranteeing that APRNs view the provision of health care from a nursing perspective has implications for graduate curricula. The American Association of Colleges of Nursing (AACN, 2006) includes nursing theory as a component of its document Essentials of Doctoral Education for Advanced Practice Nursing. Students also need assistance in utilizing this theoretical content in their practice. Faculty and preceptors who model this approach for advanced practice nursing students are critical for helping them integrate theory into practice and to build bridges over the theory to practice gap that currently exists. APRNs provide health care to many individuals and populations in diverse care environments and settings. APRNs have the opportunity to make major contributions to advance the nursing profession. By focusing on the nursing elements of health care, APRNs have the opportunity to demonstrate to the public and to policy makers the unique and significant contributions that nursing has on health outcomes. In using nursing frameworks rather than the medical model as the focus of practice, APRNs provide the public with a distinct and adjunctive model of care rather than a substitutive model (i.e., replacing physicians). APRNs may carry out activities that have traditionally been a part of medicine, but the manner, approach, style, and performance of these activities by APRNs need to be translated into the realm of nursing. Acknowledgment The author acknowledges the contributions of Michaelene Jansen to this chapter in the previous edition. Blair_72518_PTR_02_027-040_03-20-15.indd 36 20/03/15 12:53 PM